Employee Identification Badge/ Access Card Replacement Form s1

Parking Permit Registration Form OSB Security Office’s Telephone Number: (225) 219-4799 Fax the completed and signed form to (225) 219-9309

Employee’s Information First Name: M.I. Last Name: Agency: Building Name: Telephone (work):

Vehicle and Decal No. Information

For OSB Internal If you have been issued a Number of Vehicle License Use Vehicles Number surface lot “Parking Gate Decal # Issued Access Card” (White Card), 1 please provide the Card # in the box below: 2 3 4 Card No. 5

Terms and Conditions By signature below, I acknowledge and agree that the parking decal(s) I am issued, permitting me to park in a state owned parking lot and/or Garage under the supervision of the Office of State Buildings, are for my personal use of my privately owned vehicle(s). I understand that:

1. I must display the parking decal in the manner as noted on the bottom of this form. 2. I am not permitted to park in a FIRE ZONE, in a space marked for HANDICAPPED persons (unless I have a handicapped permit), in a space RESERVED for others, in a NO PARKING area, in a DRIVEWAY or in LOADING ZONES. 3. I am not permitted to park on lawns, sidewalks, grassed areas, in construction areas, or where parking will physically mar landscaping, create a safety hazard, interfere with the use of facilities, or hinder the free movement of traffic. 4. The decal must be displayed on the front windshield directly above or below the state inspection sticker. No other location will be acceptable.

Employee Signature Date

Parking Coordinator Signature Date

Parking Coordinator Printed Signature Date